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A Scope Instead of Surgery

Patients and health-policy experts don’t see eye to eye on everything, but there’s one point they agree on: If a noninvasive technology can make exploratory surgery unnecessary, go for it. And for some patients with gallstones, pancreatitis, tumors of the stomach and bile ducts and similar gastrointestinal ills, that’s just what the ERCP Spyglass does.

The Spyglass is “a scope for a scope” that can help to diagnose and treat certain hard-to-treat diseases. (ERCP stands for—take a breath—endoscopic retrograde cholangiopancreatography.) It combines endoscopy (looking inside the body with a lighted tube) and fluoroscopy (an Xray- based moving-image technology) to diagnose and treat certain problems of the bile or pancreatic duct systems.

Through the endoscope, the physician can see the inside of the stomach and duodenum (the upper part of the small intestine) and inject contrast dye into the bile and pancreatic ducts so they can be seen on X-rays. ERCP is used primarily to diagnose and treat conditions of these ducts, including gallstones, inflammatory strictures, leaks (from trauma or surgery) and cancer. It allows doctors to see further into the body and identify smaller obstructions than is possible with other devices, possibly sparing the patient the ordeal of exploratory surgery.

Though ERCP is a potent diagnostic tool, the development of safe and relatively noninvasive procedures such as magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound means that ERCP is now rarely performed just to diagnose, says Edward Lebovics, M.D., Chief of Gastroenterology and Hepatobiliary Diseases at Westchester Medical Center.

“What makes it important is that it allows us to provide therapy for the problem as well,” he says. He describes the procedure this way: The endoscope, a flexible tube-like instrument with a video chip on its tip, is passed through the mouth to the stomach and small intestine. Once inside, it can identify the pinhole-size openings of the bile and pancreatic ducts, where those organs’ digestive juices and enzymes flow into the bowel. Then the physician can pass a cannula, a thin catheter, into the duct, inject contrast dye and take pictures to diagnose problems.

The most common problems in the bile duct are stones and strictures (narrowings), which can be caused by tumors either benign or malignant, he says. The pancreas also presents strictures and stones, as well as tumors, cysts and other malignant or premalignant conditions. If Dr. Lebovics finds a bile-duct obstruction such as a stone, he can then make a small incision using a surgical instrument inserted through the cannula into the opening of the duct. “This makes the opening larger, and then we can put a device into the duct to pull the stone out,” he says.

“For a stricture, we can dilate the opening with a balloon and put in a stent to keep it open—either a temporary plastic stent or a more permanent metal one.” He can also treat more serious conditions such as pancreatic cancer. “If we see that a duct is obstructed by a tumor that does not need major surgery to be removed, we can place a stent in the duct and then manage the cancer with chemotherapy,” he says.

“Many cancer cases come in to us for staging and possible duct repair prior to major surgery.” The ERCP Spyglass is available at many medical centers, he says, but the most challenging cases in our area are referred to Westchester Medical Center—including those in which previous ERCP treatment attempts have failed. It can be very tricky placing the scope and surgical instruments in exactly the right position, especially in patients whose anatomy has been altered by previous surgeries or congenital abnormalities.

“ERCP is probably the most challenging of all endoscopic procedures and has the highest risk of complications,” says Dr. Lebovics, explaining that among these complications are bleeding, perforation and inflammation of the tissue. “The technique requires special training. Fellowship-trained gastroenterologists have an additional year of special training in this. It is a very advanced technique best done by experienced surgeons.”


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